The pilot projects try to cover a variety
of communities and to use a variety of ways to expand testing. They are:
- Leicester: HIV testing of all 15 to 59 year olds admitted to hospital. Because
Leicester is an area on the cusp of the
0.1% general prevalence rate recommended by BHIVA, this will inform cost-effectiveness
- Sheffield: piloting home-sampling test kits among MSM (taking a saliva-based
test at home but getting the result back from the clinic by phone). In a
previous pilot project run in Brighton,
the return rate of home-sampling kits when offered was 80%.
- Brighton 1: offering opt-out testing to all 15 to 59 year olds when
registering with 19 GP practices. Brighton
has ongoing ‘Locally Enhanced Service’ GP practices that deal with HIV
(see HTU 184), which this pilot
- Brighton 2: routine testing of hospital admissions, similar to the Leicester project, but in a high-prevalence town.
- London 1: comparing opt-out testing in three different hospital settings:
acute admissions, people having operations, and all accident and emergency
cases, in three hospitals (Homerton, King’s College and Chelsea
- London 2 (Lewisham): opt-outHIV testing
in up to ten local GP practices, including some with high numbers of black
- London 3 (THT):
mobile HIV testing unit, going around money
transfer shops and other venues frequented by Africans. Will use an
“assertive case finding approach”, which means using interviews to
estimate risk before offering a test.
- London 4: The GMI partnership/Positive East. GMI is an HIV prevention partnership for gay men formed by Positive
East, the Metro Centre and the West London Gay Men’s Project. This pilot
compares the acceptability of two testing approaches. One offers HIV
testing as part of a general health screen to Africans at Positive East.
Another uses either nurses or peer educators to offer tests to gay men at
the GMI Partnership organisations. The acceptability of partner
notification will also be tested.
Martin Fisher is the HIV consultant at Brighton and Sussex University
Hospital, who chaired the
group that wrote the BHIVA testing guidelines. “I’m involved in the two Brighton projects, which we started in August,” he says.
Fisher is open-minded about which settings
are likely to encourage more people to test and to increase the HIV diagnosis
rate. “We need to find out where the BHIVA Guidelines were right and where they
He has some reservations about non-GUM
testing sites, and particularly about the idea of community-venue testing.
“We have already had one pilot project in Brighton offering gay men a rapid test result in 30
minutes,” he says. “We did get a number of predominantly high-risk young gay
men using the service as an alternative to going to a GUM clinic. But the point
is that an HIV test is all they got.
We encouraged them to go to the GUM for an STI
check-up too, but most didn’t. As a result, we have just started offering tests
for all blood-borne viruses (hepatitis A, B and C plus syphilis) when people
attend our ongoing community testing service at [Terrence Higgins Trust] THT South.”
He also stresses that there’s no point in
offering people HIV tests unless you have very good referral processes in place
for those who do test positive. Next month HTU
will look at the alarmingly high number of patients who disappear from care
after getting a positive test result. Community testing without good clinical
referral may increase the risk of them disappearing.
Finally, Fisher is concerned about the
continuing problem of false positives given by the while-you-wait tests, at
least in low-prevalence populations.
The kind of fingerprick HIV test used in ‘point-of-care
testing’ (POCT) is up to 99.8% specific. What this figure actually means is
that in a population where one in ten people has undiagnosed HIV, 982 in every thousand
positive test results will be correct diagnoses and 18 will be false positives,
which can be eliminated by confirmatory tests.
However in a population with only 0.1% HIV
prevalence, only one third of positive test results will be correct, and
two-thirds will be false, before the confirmatory test. Clearly screening such
a low-prevalence population would generate a lot of needlessly anxious people.
The kinds of tests feasible in community settings, without immediate hospital
laboratory back-up, may only really be suitable for high-prevalence populations.
Informed by the results of the Department of Health-funded
pilot studies, NICE, the National Institute of Health and Clinical Excellence, plans
to write its own guidelines on what kind of testing protocols will best detect
HIV for gay men and Africans. It has just issued the first public consultation,
requesting input on exactly what these guidelines should and should not cover.